1. MSM Syphilis Prevention: Sexual Identity and Intersecting Social Networks FR Bloom, A Goodfellow, M Berry, and MM Hayes Centers for Disease Control and Prevention

2. Background MSM Syphilis in Los Angeles Initial reemergence of MSM syphilis in 2000 Recurrent MSM syphilis increases since 2002 through present Common characteristics of syphilis increases –Drug use –HIV positive –LA County Gay Men’s Lock-Up (K-11 Unit) –Transgender MTF

3. Background II Transgender MTF and STDs in LA Social Stress –Stigma and unemployment –Cost of hormone therapy and surgery –Unstable residence patterns –Depression Drug use –Sex trade

4. Technical Assistance I Rapid Ethnographic Assessment Conversation and Observation: June 2005 –Public Health Investigators (PHI) & Staff (n=10) –K-11 Deputies (n=2) –MSM street intercept (n=12) »STD mobile testing van Revisit: February 2006 –Public Health Investigators (PHI) and STD Program staff (n=12)

5. Technical Assistance II Syphilis Case Reports: Preliminary Review 47 Syphilis cases with history of incarceration –January – June, 2005 –41 (88%) male cases –31-38 (66% - 81%) MSM –15 (32%) HIV+ MSM 5 (11%)Transgender MTF identified by PHI narrative –2 (4%) Transgender HIV + 1 heterosexual-identified male with Transgender partner

6. Findings I Rapid Ethnographic Assessment Continuity of Services –LA County Health Department and County Jail –Service referrals (Medical, mental health, social) Determining Sexual Identity –PHI observation versus self identity –Biological determinates versus social determinates Chasing Syphilis versus Syphilis prevention –Keeping up with technology –Staffing needs, time, effort, and results

7. Findings II: Syphilis Case Reports The Context of Incarceration 83%Drug use and addiction 15%Homelessness or unstable residence 68%Anonymous partners 89%Unprotected penetrative sex 34%Sexual risk while in jail 6%Travel out of area 35%Trading sex for drugs/money --Referral issues --Casewatch system deficits »transgender or other MSM identity

8. Findings III Intersecting Social Networks MSM as an artificial category with limited use Diversity and conflict: gender identity for MSM K-11 as milieu of intersecting social networks –Gay-identified men –Bisexual-identified men –Transgender Bridging and intersecting networks –Place versus population

9. Recommendations I Gender and Public Health Increase public health capacity to capture transgender and other MSM identities –Focus on identity beyond biology in interview –Enhance open-ended approach to data collection Increase capacity to capture field note data Improve understanding of gap between observer categories and client gender-identity –Gender identity is key to disclosing behaviors and social networks

10. Recommendations II Response and Implementation Casewatch capacity and gender-identity –Transgender and other identities added to program Referral list distributed and referrals increased One of four open field FTEs filled –2 additional PHI temporarily added Continued collaboration at LA County Jail –STD testing and treatment

11. Implications I Syphilis Prevention for Transgender MTF Biological Facts versus Social Identities –Social identities reveal networks –Social identities add context to behaviors –Social contexts Venues Access to care Communities Cofactors (homelessness, unemployment)

12. Implications II Syphilis Prevention Sustainability Sustainable prevention for MSM –Based on gender identity Cross-cutting or targeted –Recognition of instability of behavior change –Target social and health services to improve sustainability Change in services over change in end-user –Use of collaboration to improve service access, treatment, and prevention